What beta blockers (beta-adrenergic blocking agents) can be used for migraine prevention?

Beta Blockers for Migraine Prevention

First-Line Beta Blockers with Proven Efficacy

Propranolol (80-240 mg/day) and timolol (20-30 mg/day) are the only beta blockers recommended as first-line agents for migraine prevention, with propranolol having the strongest evidence base. 1, 2

Propranolol

• Propranolol is the most extensively studied beta blocker for migraine prevention, demonstrating efficacy in 19 of 21 controlled trials. 3
• The American Academy of Neurology and American Headache Society classify propranolol as Level A evidence (effective and should be offered to patients). 4
• Dosing range: 80-240 mg per day, initiated at low doses and titrated slowly. 1, 2
• Propranolol is superior to other agents for patients with pure migraine (without tension-type headache features). 1
• Clinical benefits may not become apparent for 2-3 months, requiring an adequate trial period. 1, 2

Timolol

• Timolol is the only other beta blocker with Level A evidence for migraine prevention. 4
• Dosing range: 20-30 mg per day. 1
• Good evidence supports its efficacy alongside propranolol. 1

Other Beta Blockers with Supporting Evidence

Metoprolol

• Metoprolol has demonstrated effectiveness in controlled trials for migraine prophylaxis. 3, 5
• The American Academy of Neurology classifies metoprolol as Level A evidence. 4

Atenolol and Nadolol

• Both atenolol and nadolol have been shown effective in double-blind clinical trials. 3, 6, 5
• These agents represent alternative options when propranolol or timolol are not tolerated. 3

Bisoprolol

• Bisoprolol has been demonstrated effective in migraine prophylaxis. 5

Critical Contraindication: Beta Blockers with Intrinsic Sympathomimetic Activity (ISA)

Beta blockers with ISA are completely ineffective for migraine prevention and should never be used. 2, 3

• Ineffective agents include: alprenolol, oxprenolol, pindolol, and acebutolol. 3, 5
• The only property consistently correlated with anti-migraine efficacy is the absence of ISA. 3, 6
• Drugs without ISA are effective; partial agonists are not. 3

Common Side Effects and Monitoring

• Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia, though these are generally well tolerated. 1, 2
• Monitor for mood changes, particularly depression. 2
• Monitor for sleep disturbances. 2

Absolute Contraindications

• Bradycardia 2
• Heart block 2
• Hypoglycemic episodes 2
• Hypersensitivity to the specific beta blocker 2

Treatment Initiation and Duration

• Start with low doses and increase slowly to minimize side effects. 1, 2
• An adequate trial requires 2-3 months at therapeutic doses before declaring treatment failure. 1, 2
• After achieving stability, consider tapering or discontinuing the medication. 1

Clinical Decision Algorithm

For pure migraine: Choose propranolol 80-240 mg/day as first-line. 1

For mixed migraine and tension-type headache: Consider amitriptyline instead, as it demonstrates superior efficacy in this population. 1

If propranolol fails or is not tolerated: Trial timolol 20-30 mg/day or metoprolol. 1, 4

Never use: Beta blockers with ISA (pindolol, acebutolol, alprenolol, oxprenolol). 2, 3